A 52-year-old man, presented with history of chest pain and sweating. His Chest X-Ray showed a suspicious double density through the shadow of left ventricle. He was referred for CT/MRI of chest for further evaluation. This is his Chest X-Ray PA View. What is your differential diagnosis?Do you suspect anything? What will you do next?

The CXR shows a double density through the shadow of LV. In addition, a tiny shadow is also seen in the right paraspinal region just below the cardiophrenic angle. This is however, rather subtle. The differential diagnosis with these findings and the clinical story would be an aneurysm, or a left paraspinal neurogenic mass. The Radiologist concerned performed a barium study. What is the diagnosis? Besides the differential diagnosis mentioned above, a large obstructed hiatus hernia could exactly look like this. This was suspected rightly and a barium swallow examination was performed instead. These are the films from his barium study.

This is a para-oesophageal type of hiatus that has obstructed. These hernias can present with symptoms and signs identical to ischemic heart disease/angina, in addition to the well-known presenting signs and symptoms of hiatus hernia.